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AusPharm CE
Lifestyle factors…
Published 15/12/2011
Lifestyle factors and impact on medicines: You are what you eat!
Learning objectives:
Provide practical evidence-based information on the impact of foods on medications and health
Advise patients on diets proven to reduce cardiovascular morbidity and mortality
Assess dietary modifications for prevention of gout
Counsel patients on calcium and vitamin D supplements for optimal bone mass and in conjunction
with anti-osteoporotic medicines
Counsel patients with or without hypertension on the benefits of dietary salt reduction
The 2010 Competency Standards addressed by this activity include (but may not be limited to): 4.2.2, 6.1.2, 6.2.1, 6.2.2,
7.1.1, 7.1.2, 7.1.3, 7.1.4.
Lifestyle interventions are an important adjunct or precursor to pharmacotherapy. Debate continues on
the value of vitamin and mineral supplements, with several commonly used dietary vitamin and mineral
supplements shown this year to be associated with increased total mortality risk.1 The National
Preventative Health Taskforce has focused on the three key areas to tackle the burden of chronic disease obesity, tobacco and alcohol.2 One third of all cancers are caused by 4 common lifestyle factors —
tobacco, diet, alcohol, and obesity.3 Lifestyle interventions reduce cardiovascular risk and risk of diabetes
mellitus, and improve quality of life.4Dietary modifications for cardiovascular risk reduction,
includingplant-based diets, have been shown to improve lipidstatus, obesity, hypertension, systemic
inflammation, insulin sensitivity, thrombosis, and cardiovascular event risk.5On a global scale, the 52nation INTERHEART study found that diets high in fruits and vegetables were associated with substantially
lower riskfor acute myocardial infarction compared with the Western diethigh in meat, eggs, and fried
Whilst there are many myths around the preventive benefits of food and specific diets, pharmacists have
a responsibility to understand and advise patients on evidence-based interventionsfordiet and
medications. This may be drug-food and alcohol interactions, or dietary prevention and management of
chronic diseases.
Some highlights of evidence published this year include:
People who eat baked or grilled fish once a week are up to five
times less likely to develop cognitive decline;7
Higher sodium-potassiumratio is associated with significantly
increased risk of cardiovascular diseaseand all-cause mortality;8
AusPharm CE
Lifestyle factors…
Published 15/12/2011
Dietary fiber may reduce the risk of deathfrom cardiovascular, infectious, and respiratory
diseases;9 and
Nut consumption improves blood lipid levelsin a dose-related manner, particularly among
subjects with higherLDL-C or with lower body mass index (BMI);10 and
Lifestyle modifications can prevent type 2diabetes among overweight people with impaired
fasting glucoselevels.11
In addition, there has been further evidence against the use of many drugs for primary prevention. For
example, analysis of the JUPITER (Justificationfor the Use of Statins in Primary Prevention) study does
notsupport the use of statins for primary prevention.12
Lifestyle modification
Lifestyle modification is the first step in the management of many chronic diseases such as diabetes
mellitus, heart failure, hypertension, coronary heart disease and dyslipidaemia. Lifestyle changes and,
especially dietary interventions are cost-effective means for the prevention of cardiovascular disease.13
In 2003 the concept of the Polypill was first proposed containing six pharmacological components (statin,
ACE inhibitor, beta-blocker, thiazide diuretic, folic acid aspirin) that by modifying different risk factors
ofcardiovascular disease multiplicatively might reducethe levels of cardiovascular disease in the
populationby more than 80%.14 The 2004 Christmas edition of the BMJ then suggested a more natural,
safer, and probably tastierstrategy than the Polypill.15 The evidence based recipe included wine, fish, dark
chocolate, fruits,vegetables, garlic, and almonds.Combining the ingredients of the Polymeal would reduce
cardiovascular disease events by 76%.
% reduction in risk of CVD
Wine (150mL/day)
Fish (114g four times/week)
Dark chocolate (100g/day)
Fruit and vegetables (400g/day)
Garlic (2.7g/day)
Almonds (68g/day)
Combined effect
Table 1 - Cardiovascular disease risk benefits of Polymeal
Mediterranean diet
The Mediterranean diet emphasizes fruits, vegetables, legumes, and complex carbohydrates; and includes
a moderate consumption of fish, olive oil, and red wine; and minimises simple carbohydrates. Data
AusPharm CE
Lifestyle factors…
Published 15/12/2011
showing that Mediterranean diet is healthy first originated from the Seven Countries Study, published 25
years ago.16 Adherence to this diet has been linked to lower chances of dying from a heart attack, stroke
or other vascular events.17 In a recent meta-analysis of 530,000 participants from 50 studies, greater
adherence to the Mediterranean diet was associated with a lower risk for metabolic
syndrome.18Adherence to the Mediterranean diet has an additional protective effect on the development
of an acute coronary syndrome (ACS) or ischemic stroke.19
Gout and diet
The ageing population, increasing obesity and lifestyle changes are likely to make gout more common in
the general population. The peak age of onset in males is 40 to 60 years, whereas it is somewhat later in
females. The prevalence increases with age and is higher among men than among women, with a ratio of
3 or 4 to 1 overall. However, this sex disparity decreases at older ages, at least in part because of declining
levels of oestrogen, which has uricosuric effectsin women. Optimal management of gout is important as
hyperuricaemia is associated with increased CV risk.
The increased availability of purines from any of either exogenous,
dietaryorendogenous sources, or tissues leads to excess urate (hyperuricaemia),
either by overproduction or under excretion.Obesity associated with increased
production and reduced excretion of urate.20
Restriction of exogenous purine intake through dietary modifications or the use
of xanthine oxidase inhibitors (e.g. allopurinol) to block uric acid synthesis from
endogenous purine metabolism can reduce the amount of urate that contributes
to the total-body urate pool.
Purine-rich foods include:
meat (beef, pork, or lamb; processed meat, including sausage, salami, andbologna; bacon; hot
dogs; hamburgers; poultry,including chicken and turkey; chicken liver; andbeef liver);
seafood (tuna; dark fish; other fish; and prawns, lobster, or scallops); and
purine-rich vegetables(peas, beans, lentils, spinach, mushrooms, oatmeal,and cauliflower)
Moderate intake of purine-rich vegetables or protein is not associatedwith an increased risk of gout.21
Drinking 4 or more cups of coffee a day reduces the risk of gout for men and women.22,23
Epidemiological data suggests that a diet rich in low fat dairy productsdecreases serum urate
concentration; whereas diets containing meat, fish, alcohol (particularly beer and spirits) increase serum
urate concentration.20,21 For example, one additional portion of low fat dairy product can reduce the risk
of the first attack of gout by 21% and one additional serve of alcohol per day increases the risk by nearly
No controlled trials of the effect of lifestyle change onthe incidence of recurrent gout have been carried
out. Adherence to traditional low purine diets is poor andthey are not usually recommended. Patients
with gout who are obese (body mass index > 28), or who haveone or more alcoholic drinks per day, should
be advised to lose weight or decrease their alcohol consumption, or both to prevent recurrent gout.20 Data
from the Health Professionals Study, a large ongoing longitudinal study involving 51,529 men aged 40 to
AusPharm CE
Lifestyle factors…
Published 15/12/2011
75 years in 1986, however, suggest that thefollowing relatively simple changes may have animpact on
incidence of recurrent gout:
Lose weight
Eat one less portion of meat or fish a day
Drink wine instead of beer
Drink a glass of skimmed milk a day
One of the most widely debated topics in 2011 was whether a reduction in dietary salt impacts on
cardiovascular mortality and all-cause mortality. In aCochrane reviewthe relative risks for all-cause
mortality and cardiovascular mortality for both normotensives and hypertensives were only mildly to
moderately reduced, and not to a statistically significant degree.24 In patients with heart failure, salt
restriction actually significantly increased all-cause deaths.24 A comment in The Lancet suggested that the
“Cochrane reviewand the accompanying press release reflect poorly on the reputation of The Cochrane
Library and the authors.25 Whilst currently available data from RCTs is not sufficient to demonstrate
statistical significance for reductions in mortality or CV morbidity, the Cochrane review should not be
interpreted as ruling out a clinically significant benefit on long term outcomes and should not deter
people from following public health dietary advice regarding salt intake.
In Australia, the estimated average consumption of salt is 10 grams per day for men
and 7 grams per day for women.26 Reducing average salt intake by 3 grams per day
would be expected to lead to a 22% reduction in deaths from strokes and a 16%
reduction in deaths from coronary heart disease.26
Raised blood pressure (BP) is one of themost common and preventable riskfactors
for cardiovascular disease. Many trials have shown that a diet rich in fruits, vegetables, low-fat dairy
products, small amounts of red meat and sugar-containing beverages, decreased amounts of total and
saturated fat and cholesterol lowers blood pressure (BP). The DASH diet has been shown to lower BP at
high, intermediate and low levels of sodium intake.27 A reduction in sodium intake to less than
100mmol/day (2.3g Na or 5.8gNaCl) in addition to the DASH diet lowers systolic blood pressure (SBP) by
7.1 mmHg in patients without hypertension and 11.5 mmHg in patients with hypertension.27 The
combined effects on BP of low sodium intake and DASH diet are greater than the effects of either alone.27
Australian data has shown reducing sodium intake by 100 mmol/day is associated with 2.3 mm Hg
reduction in SBP.28
Urinary potassium, reflectingdietary intake, has been shown to have anindependent inverse association
with BP, meaning that lower potassium intakes increases risk for elevated BP and hypertension. High
urinary sodium-to-potassium ratio increases CV risk and mortality, independent of effects on BP.28
Current best available evidence suggests that salt reduction is beneficial in people with or without
hypertension and may be associated with reduction in cardiovascular disease, stroke and all-cause
mortality.However, no randomised controlled trials have studied the effect of reducing salt intake of
populations on cardiovascular disease. The health benefits of a Mediterranean-style diet may be
compromised by its high salt content.29
AusPharm CE
Lifestyle factors…
Published 15/12/2011
Significant reductions of salt intake from diet are difficult unless processed food salt is reduced or people
have diet high in fruit and vegetables and little processed food.
Bone health
The evidence for adequate calcium and vitamin D by diet, sun exposure or supplements continued to grow
in 2011. Adequate calcium and vitamin D intake, and exercise are important for reaching and maintaining
optimal peak bone mass. Average dietary intake of calcium in Australia is below recommended levels and
there is strong evidence of vitamin D insufficiency and deficiency, especially in residential care and high
risk persons.30 Calcium supplements are only needed when dietary intake is insufficient and usually only in
low doses due to concerns for increased risk of myocardial infarction.31,32
Key messages for healthy nutrition for bone health include:33
An adequate calcium intake (1000mg dietary intake of calcium a
day is recommended for all adults and 1300mgis recommended
for women aged over 50 years and men aged over 70 years),
should be ensured at all stages of life;
Dairy foods, calcium-set tofu, some green vegetables, nuts, and
small canned fish with soft bones provide the most readilyavailable sources of dietary calcium;
An adequate supply of vitamin D is required, through sufficient exposure to the sun, through diet,
or through supplements;
Adequate protein intake is necessary. Protein malnutrition is an important risk factor for hip
fracture, and can also contribute to poor recovery in patients who have had a fracture;
Excessive alcohol consumption should be avoided;
Being underweight is a strong risk factor for osteoporosis (body mass index < 18.5 kg/m2);
If on a weight-reducing diet, ensure adequate intakes of calcium and vitamin D, and avoid 'fad'
diets in which whole food groups are severely restricted or eliminated;
Include plenty of fruits and vegetables in the diet, as these are beneficial for both bone and
overall health;
Magnesium is involved in calcium homeostasis, and in the formation of hydroxyapatite (bone
mineral). However, there are no studies to date which demonstratethat magnesium
supplementation is useful either inpreventing bone loss or reducing fracture risk;
Concerns have been raised that consumption of carbonatedsoft drinks, notably cola drinks, may
adversely affectbone health. Although a few observational studies haveshown an association
between high carbonated beverageconsumption and either decreased BMD or increasedfracture
rates in teenagers, there is no convincing evidencethat these drinks adversely affect bone health;
In addition to a nutritious diet, other complementary lifestyle practices such as taking regular
exercise and avoiding smoking help to maintain bone density.
AusPharm CE
Lifestyle factors…
Published 15/12/2011
Lifestyle modification is first-line therapy for many chronic conditions and should be considered in
conjunction with pharmacotherapy. Pharmacists should provide support and information to consumers in
conjunction with prescription and over-the-counter medicines.
Debbie Rigby
12 December 2011
1. Which combinations of foods have been shown to reduce cardiovascular disease?
a. Low fat dairy foods, beer, garlic
b. Purine-rich vegetables, garlic, almonds
c. Wine, dark chocolate, almonds
d. Coffee, fish, red meat
e. Fish, red wine, eggs
2. Which of the following lifestyle modifications are most likely to reduce the risk of recurrent gout?
a. Drinking beer instead of wine or spirits
b. Reduction in body weight and alcohol consumption
c. Decrease in low fat dairy products
d. Decrease in purine-rich vegetables
e. Reducing coffee intake
3. Which of the following statements regarding gout is correct?
a. The incidence of gout in women decreases after menopause
b. Obesity is associated with increased production and increased excretion of uric acid
c. Xanthineoxidase inhibitors block uric acid synthesis from exogenous purine intake
d. Hypouricaemiais associated with increased cardiovascular risk
e. Gout is more common in middle-aged males than pre-menopausal women
4. Which of the following statements regarding dietary salt is not supported by current evidence?
a. Lower sodium excretion is associated with a higher risk for cardiovascular disease
b. Reducing sodium intake is associated with a reduction in systolic blood pressure
AusPharm CE
Lifestyle factors…
Published 15/12/2011
c. Higher potassium intake increases risk for elevated BP and hypertension
d. Combined effects on BP of low sodium intake and DASH diet are greater than the effects
of either alone
e. Epidemiological studies suggest lower salt intake results in a reduction in stroke and heart
5. Which of the following best describes the calcium and vitamin D daily requirements for a 75-yearold postmenopausal woman consuming a non-vegan diet and receiving inadequate daily sunlight?
a. 1300 mg of calcium and 800 IU of vitamin D
b. 1000mg of calcium and 400IU of vitamin D
c. 600mg of calcium and 200IU of vitamin D
d. 1200mg of calcium and 400IU of vitamin D
e. 2000mg of calcium and 200IU of vitamin D
Mursu J, Robien K, HarnackLJ, Park K, Jacobs Jr DR.Dietary Supplements and Mortality Rate in Older Women: The
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Parkin M, Boyd L, Darby SC, Mesher D, Sasieni P, Walker LC, et al.The Fraction of Cancer Attributable to Lifestyle and
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Keys A, Menotti A, KarvonenMJ, Aravanis C, Blackburn H, Buzina R, et al.The diet and 15-year death rate in the
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Gardener H,Wright CB, Gu Y, Demmer RT, Boden-Albala B, ElkindMSV, et al. Mediterranean-style diet and risk of
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